Erika’s note: This is not a short essay. Don’t say I didn’t warn you. I’m pouring practically everything I know about the health care industry into one essay, and I hope you find value in it.
When I was 8 months pregnant, I attended BlogHer 2015, here in NYC. During the lunch keynote, I sat at a table full of some of my favorite fellow bloggers as we watched a trailer for a documentary that Christy Turlington was working on, for her organization Every Mother Counts. It was about how maternal care is so abysmal in this certain part of the country, how women were dying in childbirth at rates that were higher than most other parts of the country. I saw this beautiful brown face, a woman whose name escapes me but whose face I could pick out of a lineup even years later, talking about the women she helps as a doula and how she’s literally out here saving lives. Care providers in the area are so scarce, that even a little involvement from a doula can help save a woman’s life.
Then, she talked about Bed-Stuy, and then it hit me—she’s talking about Brooklyn. These embarrassingly high maternal death rates are…in New York City. Black women are three to four times as likely to die from complications of childbirth compared to their white peers. After reading this, I suspect it’s easy to guess which parts of New York City are contributing to this astronomical maternal death rate.
My mother worked in insurance for as long as I could remember. She started out as an underwriter for a company in Cleveland that, once it was bought out by a larger company, packed us up and relocated us to the suburbs of Indiana, giving almost 30 years of her life to this company. Because of this, for as long as I’ve remembered, I’ve always had health insurance. The best of insurances, at that. We might’ve had roaches, and I might’ve been wearing a Starter jacket long after the trend had passed with some generic boring sneakers… but we had that insurance. We got our check-ups and shots on time. We wanted for nothing. And, when I fell from standing on top of the monkey bars because it wasn’t enough to merely climb them, the doctors in the emergency room were all too eager to do everything short of coming to our houses to check and make sure I was okay each day.
My mother studied risk and worked hard to identify trends that not only helped save her company money, but also helped them figure out what needs they could meet. She always tried to talk to me about how insurance worked from the business angle, but c’mon, Mom… I’m 15 years old and I’m trying to go to the mall with my friends—can I live?
Almost a couple of decades later, I’m surprised by how much I remember even though I know damn well I wasn’t trying to listen.
Insurance is a relationship between you, the consumer, and the insuring agency that allows for you to store your money with the agency so that you’ll always have it when you need it. The insuring agency puts the money you’ve paid into a giant pot, and the agency uses that money to pay the hospital bills of everyone who has an arrangement with that agency. They might have different kinds of arrangements—some people get pregnancy coverage, some don’t, for example—but if a person receives the kind of medical care they’ve contracted with the agency to help them pay for, then the agency pays for it out of the pot.
The agency keeps a tight lid on what they use that pot for, and how much of it they spend at any given time, and for good reason. The money they keep in the pot, they invest in the stock market and other banking products that help turn a quarter into a thirty-five cents. That might not sound like a lot, but if they’ve got lots of quarters at any given time, then that’s lots of opportunities to get that extra dime. Spending the money in the pot frivolously means there’s not enough quarters to turn into profit… so they don’t.
How do they avoid spending frivolously? By severely limiting the kinds of care they pay for, or by outright denying to insure people they can reasonably expect to spend more money than they put into the pot. Once upon a time, people with pre-existing conditions like cancer or HIV/AIDS were often denied. People who were born with birth defects who outlived their life expectancy… often denied.
It’s worth noting that, during the discussion surrounding the Affordable Care Act in its infancy, there were claims that the government would be essentially creating a death panel where elected officials would be the ones to decide who lives and who dies. What was never discussed was the fact that we already had death panels, if that’s what we want to call them. Insurance companies, which are for-profit entities beholden to investors instead of its consumers, had been deciding who gets to live or die long before the government decided to intervene.
People who were otherwise healthy while they had insurance but later in life developed a disease considered to be terminal… were given a maximum amount that could be paid out for their care over the course of their lifetime. Once that maximum was paid, the insured individual was thereafter responsible for 100% of their care, regardless of what they’d paid into the pot over the course of their lives.
People were (and, in some cases, are) also given plans that only marginally covered the typical expected types of care. As a young mother, I remember looking for insurance plans once I was off my mother’s insurance for my child and I; I could pay for care that only covered my child’s basic care like vaccinations and annual check-ups, and for $10 more I could cover my own annual check ups if and only if I didn’t need pregnancy coverage. (The insurance agent actually told me to make sure I get on birth control just to be safe.) Adding pregnancy coverage was an additional $300/month.
Insurance plans also only cover a certain percentage of your health care. You, as the patient, would be responsible for a certain dollar amount, with the insurance provider paying the remainder beyond that. The cheaper your health care coverage, the higher that amount—known as a deductible—would be.
For these reasons, many people would carry regular insurance, but couldn’t actually afford to use it unless it was an emergency.
When I gave birth to my first child a decade ago, I was young and still covered on my mother’s luxury insurance. I gave birth in a gorgeous suburban hospital, with waterfalls and stunning dark marble everywhere. The hospital room I stayed in for my c-section was a singular room for me and me alone, with a couple of couches and a bed for anyone who’d be staying with me while I was there. The food wasn’t your typically awful hospital fare; the employees were incredibly nice. Even the TV had full cable access.
This gorgeous suburban hospital, nestled in a quiet county with a median household income of $81,000, was in a place where everyone was insured. In an environment like that, the hospital doesn’t struggle to keep the lights on. In a hospital where the overwhelming majority of its patients are insured and likely not struggling to pay their bills, the employees are paid well. Time for professional development is available to all, because they don’t have trouble getting or keeping talented staff. Because the hospital can offer competitive rates, they don’t have trouble attracting top surgical talent, either.
I remember walking through Brooklyn with my husband Eddy a few years back, when we passed a giant boarded up building. He identified it as a St. Mary’s Hospital, a centuries-old facility with a long history and an even longer balance sheet. After filing for bankruptcy protection and going belly-up to the tune of over a billion dollars, the hospital and its staff said its goodbyes in 2004.
When you serve a community that isn’t covered by the luxury-grade insurance, or has the kind of insurance where only the most basic of care is covered, it means you have to turn lots of people away. You can’t provide them care for free—you have to save your beds and your employees’ time and energy for paying customers. You give them insight on how to care for themselves, and then you send them on their way knowing they can’t pay.
But people are not doctors. They can’t care for themselves, identify symptoms of larger maladies, or recognize a major shift in their breathing patterns the way a doctor can. So, when their physical condition gets so bad they can barely stand it, they go to the emergency room.
When my oldest was 13 months, she slid down my leg and bumped her chin on my knee, sending her teeth straight through her lip. I, scared out of my mind, had my mother rush us to the emergency room of that dark marbled waterfall laden hospital.
That emergency room was stark empty. So empty, in fact, that my voice echoed when I explained to the receptionist that my daughter was bleeding and I was so scared and so sorry and oh my god please help her.
It was so empty that I didn’t even have to register or give any details to the receptionist. She walked me straight back to the private room, and in walked a doctor and a nurse. They put a numbing agent on my daughter’s lip, put a stitch in it, and told me to calm down as they sent us on our way—no longer than 10 minutes. They also charged me approximately $70 per minute for the service—$700 total.
When crime started to drop in Brooklyn—and, don’t let anyone tell you otherwise; crime has been on a constant decline across the nation with the ending of the crack epidemic—there were less people needing care. When awareness campaigns began educating people on the preventative measures of HIV/AIDS, there were less people needing care. Better technology and advances in medicine meant people needed less care. Better technology might’ve meant you could charge more for the people who did need care, but could they pay it? Would their insurance cover it?
When people need care so badly they come to the emergency room, that care is administered long before the topic of insurance comes up. The goal in the emergency room is to save lives, uphold the Hippocratic oath, and help as many people as possible. Those who require extended stays, if their insurance permits, will often be sent to their rooms. Those whose insurance (or lack thereof) won’t allow for a stay, are sent away with instructions that both doctor and patient doubt will be followed.
All that care costs money. Besides Medicaid, the government’s insurance coverage option for people living below the poverty line, how’s it being paid for? How’s a hospital to balance its budget when you have too many people coming into the emergency room for care, and not enough people paying their bills? Hospitals often will “pad” their budget, with the expectation that a certain percentage of their patients won’t pay their bills, so they know there may be a 30% margin they can’t account for, and will have to consider a loss. The rest is made up for by raising the prices on the services most frequently covered by insurance. That’s how you get an insured pregnancy stay at a hospital with luxury accommodations costing, on average, $11,000 a day.
Unfortunately, a hospital like St. Mary’s in Brooklyn didn’t have enough people to price gouge in order to keep their books balanced.
Inner city communities are complex. These are areas that are more densely populated than the suburbs, but there’s far less money flowing in the cities. Suburbanites might drive in to the city to work, but they—and their money—flee the city once the work day ends. Middle class people frequently live within low-income communities, but they’re rarely spending their money there.
The money that is in the city, held by families often struggling to make ends meet, often has to be carefully budgeted and spent with precision on the items that are most important. It costs a lot of money to be poor—you can’t take advantage of deals that allow you to buy items in bulk for a cheaper per-item rate, opportunities for credit and loans often come with a far higher interest rate, which means you’re unable to buy the best and more reliable products (cars, home appliances, and so on), meaning you’re spending far more on product upkeep and replacement than the average middle class person.
The people who live in the city may not all have enough money to keep up with every day bills and the added stress of an unexpected hospital bill. On the list of priorities of things that need to be paid, a bill for services already rendered ranks pretty low.
Rural communities are often struck by the same level of poverty one might expect in the inner city, and so are their hospitals. Even worse, there are far fewer people in rural communities, which means hospitals are fighting to continue to provide the few services they can offer. Medicaid—the government-funded insurance option—might offer some cover, but in order to keep the hospital afloat, prices have to go up.
Rural communities also have issues with being able to recruit talented physicians, or keeping updated equipment, or staying properly staffed to meet the community’s needs. Rural hospitals have difficulty keeping talented care providers, often leaving the rural environment for one with better pay, more equipment to cater to their specialty, or more opportunities for professional development. Rural hospitals have the same hard time keeping up as Brooklyn’s St. Mary’s Hospital, which is a part of why so many have been closing over the years, creating what’s referred to as a “medical desert,” where it takes too long and too much energy or effort to get essential care. Pharmacists, nurses, emergency clinics, physicians… all leave. Hospitals board up. And people no longer get the health care they need.
Earlier this week, a U.S. House Representative, Jason Chaffetz, spoke about how his party’s efforts to repeal the Affordable Care Act provides Americans with choices. “And they’ve got to make a choice. And so, maybe rather than getting that new iPhone that they just love and they want to go spend hundreds of dollars on that, maybe they should invest it in their own health care.”
My first pregnancy, the one that cost me $11,000 a day for the five days I spent in the hospital, amounted to more money than I’d ever spent on a piece of electronic equipment in my entire life. It cost more than I’d spent on my entire undergraduate college education.
More importantly, my faux-gold iPhone with the 128GB storage space was purchased on a $30/month plan.
That cheap health care plan I was once offered, to cover my child’s shots and emergent care, was $100/month. Remember—adding my reproductive care was extra.
The Affordable Care Act changed lives. One needn’t look too far to find proof of that.
People who could no longer get insurance due to a pre-existing condition were now able, and they used it as is their right. Insurance companies then changed the kinds of plans they offered the rest of us to help balance their budget sheets—while I was pregnant with my second child, my pregnancy care went from “your insurance totally covers everything” to “you must pay $2,500 of your total care” all in my 9th month of pregnancy—so that we all were using less of the money in the pot.
In fact, the Affordable Care Act forced insurance companies to do a lot of things that messed with the money in the pot—providing full breast pumps to nursing parents, cover children under their parents’ insurance until the age of 26, expanding who would be covered under Medicaid and thereby saving lots of hospitals, helped make Medicare more solvent, and so on—and insurance companies responded by…changing the health care plans of those of us who’d had our plans long before the ACA stepped in, those of us who were paying much more into the pot. That’s a large part of how people “lost their doctors”—insurance companies changed the kinds of care our individual plans provided and, just like that, it was gone.
It’s easy to see why people are misunderstanding what happened with health care over the past decade—our politicians keep misrepresenting the facts.
When Republican Speaker of the House Paul Ryan spoke of the Affordable Care Act, he said “The idea of Obamacare is … that the people who are healthy pay for the people who are sick,” and represented that as if it were the same as “those of us who work hard to be able to live above the poverty line shouldn’t have to pay for those who take advantage of the system,” the same kind of argument people like him use against programs like welfare and food stamps.
For some reason, the very honest and moral argument of “everyone deserves health care” and “no one deserves to go bankrupt in an attempt to save their own—or their loved ones’—lives” goes nowhere in a majority-religious nation. The argument about caring “for the least of these” becomes oddly irrelevant and, dare I say, hostile—it becomes an issue of “hard working Americans” paying for “people who just laze around all day and don’t work hard enough.”
That’s why it’s so important to point out when politicians seemingly misrepresent something as easy to understand as “insurance.” Of course you’re paying for other people’s care—when you, or your spouse, or your child comes down with a life-threatening illness and has to endure an extended stay at the hospital, other people are paying for your family’s care, too.
But they’re hitting on an important talking point. It’s not that they’re merely hiding the truth about how insurance works—they’re galvanizing support for an otherwise harmful policy stance by pretending that the problem is people who “don’t work hard enough” to be able to afford their own care.
The distribution of wealth in the United States creates a situation where only the communities with the most money are able to have stable, reliable, technologically-advanced care, provided by trained physicians who stay current in their field and commit to continued education outside of prescribing the latest pill. It’s compromising the care that people in the poorest states in the country receive—some of the states with the highest presciption rates for opioids have more than 100 prescriptions for every 100 people.
That’s not a typo. If your doctor knows so little about your condition that all they can reference is the information inside an advertisement for a pill, guess what your doctor’s going to suggest?
What we have to understand is that a system structured around only serving those with money not only determines who gets access to care, but how easily that care is accessed. We have people who must drive hours out of the way for routine care. We have people pulling over and giving birth on the side of the road because they couldn’t reach a facility in time. The difference between the life expectancy of rural and urban residents is increasing as time progresses—rest assured, the unequal access to care is a major contributor as to why.
My mother, the insurance wizard, experienced a seizure at work while giving a presentation. She immediately tipped over, hit her head on a desk, and began convulsing on the floor. Her co-workers called 911 and she was immediately taken to the hospital, which realized they were ill-equipped to provide what she needed, so she was then rushed to another nearby hospital approximately 25 minutes away.
She underwent immediate brain surgery to relieve a ruptured aneurysm. The doctors operated on her in the evening time, well into the morning, and were laughing and joking the next day. The surgery was a success, and thank goodness. My mother, after a couple of weeks in the ICU and some occupational therapy to help spot any inconsistencies in her behavior, was as good as new. That luxury-level insurance, mind you.
Except, not even a year later, she was relieved of her position. A person with a pre-existing condition and a need for consistent care now no longer has the insurance that connected her to the people most familiar with her condition and her specific needs.
At some point, we have to ask ourselves—are we truly comfortable with all of these stories?
Are we comfortable knowing that we live in a country where a person who works and pays for her own health care her entire life can be thrown into a life of uncertainty at the discretion of her employer?
Are we comfortable knowing that those who choose to give birth in modern-day America are more likely to die in childbirth all because of where they give birth?
Are we comfortable knowing that hard-working people who make minimum wage—or close to it—will never be able to get the care they truly need?
Are we comfortable knowing how many rural hospitals are shutting down because their communities can’t afford to pay those slowly-increasing hospital fees for the care they need?
If we truly value human life the way we say we do, then we should find it abhorrent that people are forced to choose between dying and the expense of living. We need to invest in our health care system, and a universal health care system—where we all pay into one insurance provider—is the best way to do it. A universal system where we ensure that each of us has access to life-saving care that doesn’t demand we give up our entire life’s work in order to afford it is the best gift we can give to our children, and their children, and their children. A universal health care system that allows us all to have affordable preventative care, reproductive care, rehabilitative care (for those suffering from addiction), and more is the only kind of system befitting a nation as prosperous as our own.
We owe it to ourselves, our communities, and our country to value each other over the mythical and theoretical free market. If potentially risking the loss of so many lives is what it takes to have this “free market” system that some politicians believe we should have, then we much acknowledge that this isn’t “free” at all. The cost is human lives, and we should all find that appalling.
5 comments
I’m a long-time fan, but quiet lurker here. I’m also a family nurse practitioner in a low-cost clinic for underserved patients and completely concur with your assessment of these issues. Well, except for the part about people receiving care in the ER long before payment is considered. This is true if you are unconscious or medically unstable, but the majority of people, will be asked for their insurance card as they are checking in. And yes, emergency rooms are required by law to see everyone, regardless of ability to pay, but you better believe that ability to pay will vastly affect the care received while there.
For example, one of my patients came to our clinic with a prolapsed uterus. As in it was dangling out of her body. We sent her straight to the ER, and if she’d had insurance, they would have promptly admitted her and scheduled her for surgery. As it was, they merely gave her some pain medicine and sent her on her way with a referral to follow up with the surgeon in the morning. Of course, without insurance or the cash to pay upfront, the surgeon refused to see her. The ER staff had to have known this, but as long as they could document that she was medically stable and that they had given her the appropriate referral, then that’s all they’re legally required to do. Some hospitals are better about this than others. Eventually we were able to send this patient to the state owned hospital over an hour away and they did help her, but I see this type of thing play out time and again.
This is such an important clarification, and I’m truly grateful to you for making it.
That’s such a nuanced point—even if you DO go to the emergency room, not being able to pay for your care still impacts the kind of care you receive. You’re not just walking in to the emergency room and getting the red carpet treatment. You’re going in there and being prevented from dying on the spot.
Also, I can’t help but wonder whether that might be an axis in the perpetuation of prescription pain pill addiction and dependency. People who can’t afford care being prescribed pills and having to rely on the meds for peace of mind…but then becoming hooked on them. Wow, wow, wow. That’s so deep.
Thank you for coming out of lurker status to share this! This was a lot to think about.
It is absolutely certain that this contributes to opiod addiction. I have several patients who live with severe pain because they cannot afford the joint replacement/rotator cuff repair/back surgery/etc. that they need, or even just physical therapy. So as much as I hate to just throw pills at a problem, it’s just about all I can offer most of my patients. Pain pills won’t fix anything, but they will at least allow my patients enough relief that they can get out of bed in the morning and go to work to support their families. I see the same problem with mental illness. Medications are great for treating certain conditions, but they can’t fix everything. There is no pill that will teach you better coping skills or heal your past traumas. But people who can’t afford therapy often wind up taking more and more pills just to function.
Oh my gosh, this hurts to read. Ugh, ugh, ugh.
Yes, Yes, Yes! Thank you for eloquently stating the point that seems obvious to many people who are not comfortable, healthcare-for-life politicians.
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